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Medical error
In the United States medical error is estimated to result in 44,000 to 98,000 unnecessary deaths and 1,000,000 excess injuries each year. It is estimated that in a typical 100 to 300 bed hospital in the United States, excess costs of $1,000,000 to $3,000,000 attributable to prolonged stays and complications just due to medication errors occur yearly. Medical care is frequently compared adversely to aviation, in that, while many of the factors which lead to error are similar, aviation's error management protocols are much more effective. Epidemiology of medical error Medical errors are associated with inexperienced clinicians, new procedures, extremes of age, complex care and urgent care. Poor communication, improper documentation, illegible handwriting, inadequate nurse-to-patient ratios, and similarly named medications are also known to contribute to the problem. Approaches to error Traditionally, errors are attributed to mistakes made by individuals who may be penalized for these mistakes. The usual approach to correct the errors is to create new rules with additional checking steps in the system, aiming to prevent further errors. As an example, an error of free flow IV administration of heparin is approached by teaching staff how to use the IV systems and to use special care in setting the IV pump. While overall errors become less likely, the checks add to workload and may in themselves be a cause of additional errors. A newer model for improvement in medical care takes its origin from the work of W. Edwards Deming in a model of Total Quality Management. In this model, there is an attempt to identify the underlying system defect that allowed the opportunity for the error to occur. As an example, in such a system the error of free flow IV administration of Heparin is dealt with by not using IV heparin and substituting subcutaneous administration of heparin, obviating the entire problem. However, such an approach presupposes available research showing that subcutaneous heparin is as effective as IV. Thus, most systems use a combination of approaches to the problem. The field of medicine that has taken the lead in systems approaches to safety is Anaesthesiology. Steps such as standardization of IV medications to 1 ml doses, national and international color coding standards, and development of improved airway support devices has made anesthesia care a model of systems improvement in care. The profession of pharmacy has extensively studied the causes of errors in the prescribing, preparation, dispensing and administration of medications. As far back as the 1930’s, pharmacists worked with physicians to select from many options, the safest and most effective drugs available for use in hospitals Pease E. Minimum standards for a hospital pharmacy. Bull Am Coll Surg 1936;21:34-35. The process is known as the Formulary System and the list of drugs is known as the Formulary. In the 1960’s, hospitals implemented unit dose packaging and unit dose drug distribution systems to reduce the risk of wrong drug and wrong dose errors in hospitalized patientsChapter IV.1 Medication Distribution Systems, Garrison TJ (au) in Handbook of Institutional Pharmacy Practice, Smith MC and Brown TR eds, Williams and Wilkins Co. 1979, ; centralized sterile admixture services were shown to decrease the risks of contaminated and infected intravenous medicationsChapter IV.3 Developing Intravenous Admixture Systems, Woodward WA and Schwartau N (au) in Handbook of Institutional Pharmacy Practice, Smith MC and Brown TR eds, Williams and Wilkins Co. 1979, ; pharmacy computers screened each patient’s medication list for drug-drug interactionsChapter 53 The Patient Profile System, Powell MF (au) in Handbook of Institutional Pharmacy Practice, Smith MC and Brown TR eds, Williams and Wilkins Co. 1986, ; and, pharmacists provided drug information and clinical decision support directly to physicians to improve the safe and effective use of medicationsChapter 31 Communicating Drug Information, Evens RP (au) in Handbook of Institutional Pharmacy Practice, Smith MC and Brown TR eds, Williams and Wilkins Co. 1986, . Pharmacists are recognized experts in medication safety and have made many contributions that reduce error and improve patient care over the last 50 years. A 2005 study by Wendy Levinson of the University of Toronto showed surgeons discussing medical errors used the word "error" or "mistake" in only 57 per cent of disclosure conversations and offered a verbal apology only 47 per cent of the time. Examples of errors # Misdiagnosis # Medication error where a the wrong drug is administered or other confusion (wrong patient, wrong dose, wrong time, wrong route) means that the correct drug was administered incorrectly. # Giving two or more drugs that interact unfavorably or cause poisonous metabolic byproducts # Wrong site surgery such as amputating the wrong limb Methods to improve safety and reduce error # patient's informed consent policy # patient's getting a second opinion from another independent practitioner with similar qualifications # voluntary reporting of errors (to obtain valid data for cause analysis) # root cause analysis # electronic devices (e-pill medication reminders http://www.epill.com) to help patients maintain medication adherence # systems for ensuring review by experienced or specialist practitioners See also *Adverse effect (medicine) *Biosafety *Complication (medicine) *Iatrogenesis *Medical malpractice *Preventable medical errors *Swiss Cheese model of accident causation in human systems *Wrong medication - medication errors *Negligence *Patient safety *Total Quality Management References Book *Banja, John Medical Errors and Medical Narcissism, 2005 *Porter, Michael E. and Olmsted Teisberg, Elizabeth Redefining Health Care: Creating Value-Based Competition on Results, 2006 External links *Institute of Medicine's Healthcare Quality Initiative *The Leapfrog Group Provides free ratings of quality and safety at local US hospitals. *Institute for Healthcare Improvement *AHRQ Patient Safety Network *National Patient Safety Foundation *Health Care Disclosure Project Project to improve quality through public reporting of physician and hospital performance. *Hospital Compare A tool consumers can use to compare how well U.S. hospitals care for adult patients. *Joint Commission Resources An organization dedicated to improving patient safety and quality of care. *Joint Commission on Accreditation of Healthcare Organizations A private, not-for-profit organization and the nation's leader in continuously improving patient safety and health care quality. * Wu AW. Medical error: the second victim. BMJ 2000; 320: 726-727 * Reason J. Human error: models and management. BMJ 2000; 320: 768-770 * "Why Doctors So Often Get It Wrong" by David Leonhardt, New York Times, Feb. 22, 2006 * Y. Bar-Yam, Making Things Work NECSI/Knowledge Press, 2005 * PRWEB on Medical Error * Amalberti R, Auroy Y, Berwick D, et al. Five system barriers to achieve ultra safe health care. Ann Intern Med 2005;142:756-64 * Pittsburgh Regional Health Initiative, a leader in the application of Toyota-based quality engineering in health care Category:Error Category:Medical ethics Category:Healthcare :ar:أخطاء طبية :de:Fehldiagnose